A nurse is assessing a 1-month-old infant at a pediatric office. Which of the following findings requires a referral for further care?

Limited hip abduction

Equal leg length

Symmetric gluteal and thigh skin folds

Femoral head remains in the acetabulum during the Barlow maneuver

Answer and Explanation

The Correct Answer is A

Rationale:

A. Limited hip abduction: Limited abduction of the hips in a 1-month-old can indicate developmental dysplasia of the hip (DDH). This finding warrants further evaluation, such as ultrasound imaging, to rule out structural abnormalities and initiate early treatment if needed.

B. Equal leg length: Equal leg length is a normal finding and does not require intervention. Leg length discrepancies are more concerning and often associated with hip dislocation or other musculoskeletal conditions.

C. Symmetric gluteal and thigh skin folds: Symmetry in the gluteal and thigh folds is a reassuring sign that typically rules out DDH. Asymmetry would be more suggestive of a hip abnormality requiring follow-up.

D. Femoral head remains in the acetabulum during the Barlow maneuver: This is a normal finding. The Barlow test assesses for hip instability, and if the femoral head remains stable within the socket, no further evaluation is needed.

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Free Nursing Study Resources

Correct Answer is C

Explanation

Rationale:

A. Place a warm pack on the incisional area: Applying a warm pack immediately postoperatively can increase blood flow and risk bleeding or swelling at the surgical site. Cold packs are generally preferred in the immediate postoperative period to reduce inflammation.

B. Restrict fluids to 1,200 mL per day: Fluid restriction is not indicated after hernia repair unless the client has a comorbid condition like heart or renal failure. Adequate hydration supports healing and normal bowel and urinary function.

C. Elevate the client's scrotum on a pillow: Elevating the scrotum helps reduce swelling and discomfort after hernia repair, especially if the inguinal area is involved. This intervention promotes venous return and prevents complications like hematoma formation.

D. Encourage the client to sit to void: Sitting to void is not routinely necessary after hernia repair unless the client has mobility issues. There’s no specific benefit to this position in a typical male postoperative client.

A. Change the drainage tubing every 48 hr. B. Observe for drainage flow through the tubing. C. Remove the drain if output from the drain increases. D. Irrigate the drain to maintain suction.

Correct Answer is B

Explanation

Rationale:

A. Change the drainage tubing every 48 hr: Closed wound drainage systems are designed to remain intact and sterile until removal. Routine replacement of tubing can introduce pathogens and is not recommended unless there is evidence of damage or contamination.

B. Observe for drainage flow through the tubing: Monitoring the flow and character of drainage ensures the system is functioning correctly and allows early detection of complications like blockage, dislodgment, or infection.

C. Remove the drain if output from the drain increases: An increase in drainage volume can signal active bleeding, infection, or poor wound healing. Instead of removing the drain, the nurse should notify the provider for further evaluation and guidance on next steps.

D. Irrigate the drain to maintain suction: Closed drainage systems like Jackson-Pratt or Hemovac are designed to maintain negative pressure without irrigation. Introducing fluid into the system can break the vacuum seal, reduce effectiveness, and increase the risk of infection.

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A nurse is assessing a 1-month-old infant at a pediatric office. Which of the following findings requires a referral for further care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a male client who is postoperative following a hernia repair. Which of the following actions should the nurse include in the plan?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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